Chapter 2 - Physical Assessment Findings

Normal pulse rate from 1 week - 3 months

107-180

Normal pulse rate of a newborn

110-160

Normal respirations of a 12 year old or older

16-19

Normal respirations of a 6-12 year old

19-21

Normal respirations of a 2-6 year old

21-25

Normal respirations for a 1-2 year old

25-30

Normal respirations for a newborn to 1 year

30-35

Normal temperature of a 13 year old

36.6*C (97.9*F)

Normal temperature of a 7 year old

36.8*C (98.2*F)

Normal temperature of a 5 year old

37.0*C (98.6*F)

Normal temperature of a 3 year old

37.2*C (99.0*F)

Normal temperature of 3 month old

37.5*C (99.5*F)

Normal temperature of 6 month old

37.5*C (99.5*F)

Normal temperature of a 9 year old

37.6*C (98.1*F)

Normal temperature of an 11 year old

37.6*C (98.1*F)

Normal temperature of a 1 year old

37.7*C (99.0*F)

Normal pulse rate older than 10 years

50-90

Normal pulse rate from 2-10 years

60-110

Normal pulse rate from 3 months to 2 years

70-150

Expected visual acuity

Can be difficult to assess in children younger than 3 years of age Visual acuity in infants can be assessed by holding an object in front of the eyes and checking to see whether the infant is able to fix on the object and follow it Use the tumbling E or HOTV test to check visual acuity of children who are unable to read letters and numbers Older children should be tested using a Snellen chart or symbol chart

Expected gums

Coral pink in light-skinned clients, and various shades of brown or grey in dark-skinned clients Tight against the teeth

Expected lips

Darker pigmented than facial skin Smooth, soft, moist, and symmetric

How is hair distributed in a male?

Diamond shaped after puberty

Expected hair and scalp

Hair should be evenly distributed, smooth, and strong Scalp should be clean and absent from any scaliness, infestations, and trauma Assess children approaching adolescence for the presence of secondary hair growth

Expected findings of the scrotum

Hangs separate from penis Skin is rugose and loose Left testicle hangs slightly lower

Expected internal ear

In infants and toddlers, pull the pinna down and back to visualize the tympanic membrane. In children older than 3 years of age, pull the pinna up and back to visualize. The ear canal should be pink with fine hairs. The tympanic membrane should be pearly pink, or grey. The light reflex should be visible.

Expected internal eye exam

Red reflex should be present in infants Arteries, veins, optic discs, and maculae can be visualized in older children and adolescents

Expected neck

Short in infants No palpable masses Midline trachea Full range of motion present whether assessed actively or passively

Expected color vision

Should be assessed using the Ishihara color test or the Hardy-Rand-Rittler test The child should be able to correctly identify shapes, symbols, or numbers

Expected external ear

Should be free of lesions and nontender. The ear canal should be free of foreign bodies or discharge. Cerumen is an expected finding

Expected findings with the urethral meatus

Slit like with no discharge

Expected findings with the clitoris

Small No bruising or edema

Expected findings of the penis

Straight Urethral meatus on tip Foreskin might not be retractable Enlargement occurs during puberty Can look disproportionately small in obese patients

Expected findings for the anus

Surrounding skin should be intact with sphincter tightening noted if touched.

Expected findings with the labia

Symmetric Without lesions Moist on inner aspects

Expected face

Symmetric appearance and movement Proportional features

A nurse is checking the vital signs of a 3-year-old child during a well-child visit. Which of the following findings should the nurse report to the provider? a) Temperature 37.2*C (99.0*F) b) Heart rate 106/min c) Respirations 30/min d) Blood pressure 88/54

c) Respirations 30/min

A nurse is assessing a 6-month-old infant. Which of the following reflexes should the infant exhibit? a) Moro b) Plantar grasp c) Stepping d) Tonic neck

b) Plantar grasp

Expected hearing

Newborns should have intact acoustic blink reflexes to sudden sounds. Infants should turn toward sounds. Older children can be screened by whispering a word from behind to see whether they can identify the word.

Expected nails

Pink over the nail bed and white at the tips Smooth and firm (but slightly flexible in infants)

Expected extraocular movements

Might not be symmetric in newborns Corneal light reflex should be symmetric Cover/uncover test should demonstrate equal movement of the eyes Six cardinal fields of gaze should be demonstrated no nystagmus

What is the hair distribution in the female?

Appears in an inverted triangle

Expected general appearance

Appears undistressed, clean, well-kept, and without body odors Muscle tone: erect head posture is expected in infants after 4 months of age Makes eye contact when addressed (except infants) Follows simple commands as age-appropriate Uses speech, language, and motor skills spontaneously

Expected tongue

Infants can have white coatings on their tongues from milk that can be easily removed. Oral candidiasis coating is not easily removed Children and adolescents should have pink, symmetric tongues that they are able to move beyond their lips

Expected teeth

Infants should have six to eight teeth by 1 year of age Children and adolescents should have teeth that are white and smooth, and begin replacing the 20 deciduous teeth with 32 permanent teeth.

Expected lymph nodes

Lymph nodes should be nonpalpable. Lymph nodes that are small, palpable, nontender, and mobile can be expected to be found in children.

Expected nose

The position should be midline Patency should be present for each nostril without excessive flaring Smell can be assessed in older children

Expected head

The shape of the head should be symmetric Fontanels should be flat. The posterior fontanel usually closes by 8 weeks of age, and the anterior fontanel usually between 12 and 18 months of age

Expected ear alignment

The top of the auricles should meet in an imaginary horizontal line that extends from the outer canthus of the eye

Expected peripheral visual fields

Upward 50* Downward 70* Nasally 60* Temporally 90*

Expected skin

Variations in skin color are expected Temperature should be warm or slightly cool to the touch Skin texture should be smooth and slightly dry, not oily Skin turgor exhibits brisk elasticity with adequate hydration Lesions are not expected findings Skin folds should be symmetric

Expected mucous membranes

Without lesions Moist, smooth, and glistening. Pink in light-skinned clients and various shades of brown or grey in dark-skinned clients

A nurse is preparing to assess a preschooler. Which of the following actions should the nurse take to prepare the child? a) Allow the child to role-play using miniature equipment b) Use medical terminology to describe what will happen c) Separate the child from the caregiver during the examination d) Keep medical equipment visible to the child

a) Allow the child to role-play using miniature equipment

A nurse is performing a neurological assessment on an adolescent. Which of the following responses should the nurse expect the adolescent to exhibit when assessing the trigeminal nerve? (select all that apply) a) Clenching teeth together tightly b) Recognizing sour tastes on the back of the tongue c) Identifying smells through each nostrils d) Detecting facial touches with eyes closed e) Looking down and in with the eyes

a) Clenching teeth together tightly d) Detecting facial touches with eyes closed

A nurse is assessing a child's ears. Which of the following findings should the nurse expect? a) Light reflex is located at the 2 o'clock position b) Tympanic membrane is red in color c) Bony landmarks are not visible d) Cerumen is present bilaterally

d) Cerumen is present bilaterally

Expected cornea

should be clear

Expected irises

should be round with the permanent color manifesting around 6 to 12 months of age

Expected pupils

should be round, equal in size, reactive to light, and accommodating

Expected eyebrows

should be symmetric and evenly distributed from the inner to the outer canthus

Expected sclera

should be white

Expected eyelids

should close completely and open to allow the lower border and most of the upper portion of the iris to be seen

Expected eyelashes

should curve outward and be evenly distributed with no inflammation around any of the hair follicles

Expected conjunctiva

should have palpebral fissures and conjunctiva that are pink. Bulbar conjunctiva are transparent.

Expected lacrimal apparatus

without excessive tearing, redness, or discharge.